Case Presentation: We present 2 amalgamated, anonymized patient cases, based on 5 ethics consults requested at a single tertiary care hospital over the past 4 years. In the first case, Ms. M, an 89 year old woman with a past history of severe COPD, debilitating chronic back pain, and recent imaging findings suggestive of a new lung malignancy was brought to the emergency room and admitted after an intentional opiate overdose. She has no psychiatric history, and has had a DNR for at least 1 year. She is treated with Narcan and high flow oxygen and remains delirious but is expected to improve. Her daughter, who is her healthcare decision maker reports that her mother desired to be DNR due to concerns about untreated pain and poor quality of life, though she herself does not agree with this decision. Psychiatry was consulted and recommended suspending her DNR so that her medical team would not be complicit in her suicide attempt should she decompensate. The second case involves Mr. H, a 78 year old man brought to the ER after a self-inflicted gun-shot wound. He has multiple co-morbidities including heart failure and chronic pain, and a history of depression. He remains minimally responsive and there is concern for anoxic brain injury. He has had a DNR in place for several years, and his wife/HCPOA requests that it be honored.
Discussion: What values, precedents and guidelines ought to be considered in honoring a pre-existing DNR in a patient after attempted suicide? As the population ages, hospitalists are more likely to find themselves caring for medically complex patients admitted to the hospital after a suicide attempt. This can sometimes lead to complex ethical dilemmas and even conflict among teams. In both cases the primary team sought guidance from ethics. Accepted practice in the field of psychiatry is to view a suicide attempt as sign of compromised capacity, which raises concern that not offering full resuscitation measures to these patients would be ethically unacceptable. Brown et al. argue that honoring a request for DNR status can be ethically permissible in certain circumstances and propose a decision algorithm that centers on the question “If this were not an attempted suicide, would a request to withdraw care be reasonable?” We endeavor to test this algorithm against the cases of Ms. M and Mr. H while also engaging with additional insights these cases may provide.
Conclusions: These complex cases highlight the importance of interdisciplinary discussions among hospital medicine, psychiatry, and ethics as well as the value of involving surrogates and the importance of the distinction between changing code status and withdrawal of treatment. We argue that with an emphasis on interdisciplinary conversations it is possible to address many of these cases in a way the respects patients’ values and autonomy while protecting them from unnecessary harm.